Management of multivessel coronary artery disease

Optimal management of multivessel disease (MVD) is a complex medical decision with significant prognostic implications. Despite the advent of clinical and angiographic scores to aid with treatment delineation, therapy for MVD must be individualized for each patient and his/her clinical presentation. Particularly among patients with MVD, the selection of coronary revascularization with percutaneous coronary intervention versus coronary artery bypass graft surgery versus guideline-directed medical therapy (GDMT) alone is a prognostically important decision. Several patient factors including clinical presentation, severity of coronary artery disease, presence of left ventricular dysfunction and other comorbidities, and the patient's personal preferences should guide the decision making process. In this review, we discuss the management of MVD with regards to decisions of revascularization versus GDMT alone, mode of revascularization, extent of revascularization (i.e., complete versus incomplete), the strategy of angiography- versus ischemia-guided revascularization, and MVD management in the setting of an acute coronary syndrome.